- Two Incision Approach (Boyd and Anderson)
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advantages:
- two-incision technique to limits the anterior dissection and therefore may limit pain;
- may reduce injury to the radial nerve, which can occur w/ a one incision technique that incorporates drill holes thru the radius;
- rerupture is uncommon;
- following surgical repair, most pts achieve nearly normal isometric strength, & many are capable of relatively normal endurance;
- allows stronger fixation than the one incision technique:
- ref:
Surgical Repair of Distal Biceps Tendon Ruptures. A Biomechanical Comparison of Two Techniques
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disadvantages:
- supinator may have to be detached from the ulna, which would further weaken supination strength;
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synostosis (between the radius and ulna) may occur from the following:
- from stripping of the aconeus andsupinator muscles;
- from having the posterior tunnel directly over the periosteal surface of the ulna;
- from disruption of the proximal interosseous membrane and, with subsequent hematoma formation,
- from bone dust debris from burring of the radial tuberosity;
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technique:
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proximal incision:
- 3-cm transverse incision is made over the distal biceps tendon sheath;
- care is taken to avoid injury to the
lateral antebrachial cutaneous nerve;
- enter the tendon sheath and identify the tendon stump and then retracted into the wound;
- insert a core tendon suture through the end of the tendon;
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distal incision:
- the forearm is maximally pronated;
- a curved hemostat is passed through the biceps tendon sheath and is passed down between the radius and the ulna (along the medial
border of the radius tuberosity);
- it is then passed thru the common extensor muscles until it can be palpated underneath the subcutaneous tissues;
- muscle-splitting approach avoids subperiosteal exposure of the ulna in an attempt to lessen the likelihood of a proximal synostosis;
- tip of the hemostat is then palpated on the dorsal surface of the forearm to locate the position of the posterior incision;
- it is important that the curved hemostat not be passed along the ulnar periosteal surface, so as to avoid a radial-ulnar synostosis;
- 4-cm muscle-splitting incision is made and taken down to the radial tuberosity;
- an incision is then made, which allows exposure of the radial tuberosity;
- with acute repairs finding the radial tuberosity is usually possible, but the tuberosity is often obscured with delayed repairs;
- alternatively use a
posterolateral approach to the elbow;
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anchor the tendon:
- small osteotome is used to create a concavity in the tuberosity;
- drill holes are made through the radial tuberosity inorder to allow anchoring of the tendon;
- frequently irrigate the wound to remove all bone dust (to avoid synostosi);
- pass sutures thru the biceps using the weave of choice (Bunnel, Krachow ect...);
- the biceps is then retrieved thru the distal incision;
- sutures are then passed thru the tuberosity drill holes and is tied down;
- Outcomes:
- in the report EW. Kelly et al (J Bone Joint Surg [Am] 82-A: 1575-81, 2000), the authors report on a retrospective review of the results of 78 consecutive
anatomical repairs of the distal biceps tendon performed through a muscle-splitting 2 incision technique between 1981 and 1998;
- 4 of the 8 required a graft to restore length;
- complications developed after 23 (31 %) of the 74 repairs;
- complications included 5 sensory nerve paresthesias (3 lateral antebrachial cutaneous and 2 superficial radial nerve paresthesias) in 5 patients;
- 6 patients complained of persistent anterior elbow pain;
- heterotopic ossification that did not limit forearm rotation developed in four patients, a superficial wound infection developed in three, one tendon
reruptured, three patients lost forearm rotation, and reflex sympathetic dystrophy developed in one patient.
- complications developed after ten (24 %) of the 41 acute repairs (performed fewer than ten days after the injury), 6 (38 %) of the 16 subacute
repairs (performed ten to 21 days after the injury), and seven (41 %) of 17 delayed repairs (performed more than 21 days after injury).
- the authors note that most of the morbidity from repair of the distal biceps tendon can be attributed primarily to a delay in the timing of the repair and
secondarily to an extensive anterior exposure;
- the authors note that radioulnar synostosis is rare following the muscle-splitting modification of the two-incision technique;
- they also noted only one temporary PIN palsy;
- Complications:
-
Radioulnar synostosis after the two-incision biceps repair: A standardized treatment protocol.
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Permanent posterior interosseous nerve palsy following a two-incision distal biceps tendon repair.
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Proximal radioulnar synostosis after repair of distal biceps rupture by 2 incision technique. Report of 4 cases. JM Failla et al. CORR. Vol 253. p 133. 1990.
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Complications of distal biceps tendon repairs.
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Pronation can increase the pressure on the posterior interosseous nerve under the arcade of Frohse: A possible mechanism of palsy after two-incision
repair for distal biceps rupture—Clinical experience and a cadaveric investigation
Rupture of the distal insertion of the biceps brachi tendon.
Rupture of the distal tendon of the biceps brachi. A biomechanical study.
Rupture of the distal tendon of the biceps brachi, Operative versus non-operative treatment.
Distal biceps brachii tendon avulsion: a simplified method of operative repair. DS Louis et al. Am J. Sports Med. Vol 14. 1986. p 234.
Partial rupture of the distal biceps tendon.
Repair of the distal biceps tendon using suture anchors and an anterior
Distal biceps brachii repair. Results in dominant and nondominant extremities.
A method for reinsertion of the distal biceps brachii tendon. HB Boyd et al. JBJS. 43-A. 1961. p 1041.
Rupture of the distal biceps tendon: biomechanical assessment of different treatment options. WH Norman. CORR. Vol 193. 1985. p 189.
Clinical, Functional, and Radiographic Assessments of the Conventional and Modified Boyd-Anderson Surgical Procedures for Repair of Distal Biceps Tendon Ruptures.
Patrick D'Arco MEd, ATC. American Journal of Sports Medicine Vol 26 No 2 March - April 1998
